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Asked by juliettemokom
Mr. john smith Patient is a 69 year old obese (weighs 315lbs) man that presents to your office with concerns of flat, 1cm rash on
bilateral leg and chest, nausea/vomiting for 3 days. He presents with his wife (he has been married to her for 4 decades) who reported that he was splitting
wood 4 days ago and injured/tore his right shoulder. They went to his primary care physician who prescribed him naproxen 500mg bid and oxycodone. He
has been taking the naproxen but without sufficient relief in pain so he added ibuprofen 800mg bid and Tylenol extra strength which he takes 2tabs 6 times
daily. When you asked about the rash, his partner told you that it started when he took the naproxen and it spread gradually first starting at his chest,
abdomen and lower extremity. Patient’s wife also tells you his blood glucose is typically “bouncing up and down” from 80s to 300s” despite being diligent with
his insulin. His past medical history include hypertension, GERD, hyperlipidemia, type 2 diabetes, hemorrhoids, hepatitis B.
The patient social history includes living with his wife who is also a LPN. She tells you she works all the time to care to pay for bills. They have no children
and they have a farm and a chicken coup the patient tends to. The wife claims their supplemental income is insufficient to manage their expenses and asks
what she can do.
VS
BP 196/103
Pulse 99
Sao2
Temp 100.5 (axillary)
Sao2 91%
On exam, you note this:
Constitutional: Acutely ill male lying sitting in chair and lethargic but arousable. He appears to be in moderate distress due to pain.
HEENT: Oropharynx clear, No lymphadenopathy.
Eyes: PERRLA 4 mm, EOMI, sclera icteric
Neck: Supple, no JVD, no lymphadenopathy.
Cardiovascular: RRR, normal S1, S2, no MRG, 1+ pulses.
Respiratory: No respiratory distress, slightly increased effort, BS coarse with inspiratory wheezing noted throughout. No rales noted. GI: Rounded, firm and tender in RUQ, no rebound or guarding to deep palpation. Normal bowel sounds. Musculoskeletal: Moves all four extremities equally. Tenderness to LLE and decreased mobility and range of motion. No tenderness, no cyanosis, or edema.
Neuro: No gross cranial nerve deficits. Sensation intact.
Skin: Clean, warm, dry. Purpura noted to BLE from feet to knees and anterior chest and upper abdomen.
Psych: Calm and cooperative.
His labs show are as follows: WBC 20.5
Hgb 15
Platelet 176
Eosinophils 14
Neutrophils 6000
ESR 74
D-dimer 8.64
Chemistries labs
Sodium 151
Potassium 6.8
Creatinine 4.8
eGFR 15%
Blood glucose is 403mg/dl.
Urine chemistries are pending.
Medication List
Losartan * (Cozaar *) 100 MG PO 1X A DAY
Naproxen * (Naprosyn *) 500 MG PO 2X A DAY
Extra strength Tylenol 650mg
Omeprazole 40 MG PO DAILY
Insulin aspart (sliding scale)
Montelukast Sodium 10 MG PO 1X A DAY
Metoprolol Succinate SR (Metoprolol Succinate) 100 MG PO 1X A DAY
Questions
1. What do you suspect your patient has? What evidence supports your suspicion?
2. What are your interpretation of his labs? Name 2 that is important to contact the provider about.
3. What are nursing education points you will emphasize to this patient?
4. What counsel do you give to his wife?
5. What are pertinent findings on your exam worth following up on?
6. When you review his medications, what suggestions/concerns do you have that you plan to discuss with the provider?
7. Name 3 preventative care education points you will share with patient?
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SCIENCE
HEALTH SCIENCE
NURSING
NURSING NU451
